It is with much interest that we read the editorial on attention-deficit hyperactivity disorder (ADHD) by Paul McArdle (Reference McArdle2004). The argument regarding culture and ADHD was of particular interest to us.

ADHD is a condition that was unheard of in developing countries a few decades ago. However, clinicians now see it in increasing numbers. It was assumed that the extended families seen in developing countries act as a protective factor against psychiatric illness in childhood (Reference NikapothaNikapotha, 1991). The low prevalence of ADHD in developing countries was attributed to this. Many hypothesise that the increase in ADHD seen now is caused by the breakdown of the family network resulting from Western influences and urbanisation.

However, it is debatable whether this is a genuine increase in prevalence or merely a perceived increase as more cases of ADHD are detected than before. We suggest that the breakdown of the family network may be one of the causative factors for this perceived increase. In developing countries with extended and closely knit families the burden of childcare was shared among many family members. With the breakdown of this structure the responsibility of childcare falls solely on the parents. This situation is made worse by both parents having to work to meet the financial demands of a family. All these factors may contribute to a low level of tolerance. Parents who are unable to tolerate difficult behaviour may seek help from medical professionals.

A decade ago difficult behaviour was not perceived as requiring help or treatment from medical professionals but rather as a situation requiring advice or discipline from family elders and community leaders (Reference NikapothaNikapotha, 1991). This too has now changed because of increased awareness that difficult behaviour can be caused by psychiatric conditions.